VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Red Oak Manor
18360 Virgil Goode Hwy
Rocky mount, VA 24151

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: July 12, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/12/2022 9:15AM until 11:00AM. This inspection was conducted to follow-up on a previously cited high-risk violation in the area of resident care and related services. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-150-B-6
Description:	Based on staff interview, the facility is currently being operated by an acting administrator for longer than 150 days. EVIDENCE: Staff 1 became the facility?s acting administrator of record on 02/04/2022; therefore, from 02/04/2022 staff 1 only had 150 days to be the facility?s acting administrator. The inspector of record for the facility conducted an on-site inspection on 07/12/2022 and was informed by staff 1 that she had not taken her national examination meaning she was not awaiting the results of the exam nor had she become a licensed assisted living administrator. As of 08/01/2022, staff 1 still had not taken the national examination to become a licensed assisted living administrator; therefore, staff 1 has been the facility?s acting administrator for longer than 150 days.
Plan of Correction:	Staff 1: Has reached out to the Board of Long-Term Licensing, to which there is confirmation that all documentation has been turned in. And the test has already been paid for. Currently awaiting testing date and permission.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 03/15/2022, for Novolog three times daily before meals for diabetes and hold if blood sugar is less than 150. The July 2022 medication administration record (MAR) for resident 1 indicates that the resident was administered Novolog on 07/08/2022 at 4:00PM; however, there was no blood sugar reading recorded by staff to determine if Novolog should have been administered or held. 2. The record for resident 2 contained a physician?s order, dated 04/01/2022, for Humalog three times a day for diabetes and hold if blood sugar is less than 150. The July 2022 MAR for resident 2 indicates that the resident was administered Humalog on 07/08/2022 at 4:00PM; however, there was no blood sugar reading recorded by staff to determine if Humalog should have been administered or held.
Plan of Correction:	1. All staff has been instructed to input all blood sugar readings before administering any insulin. They will make sure at the end of every shift that every insulin dependent resident has documented all the readings. 2. All staff has been instructed to input all blood sugar readings before administering any insulin. They will make sure at the end of every shift that every insulin dependent resident has documented all the readings.